Triple – S will cover for payment the following services as medically necessary in the evaluation of a known or suspected ASD case:
· Audiological Evaluation
· Behavior Evaluation including psychiatric test
· Electroencephalograms when seizure states are suspected
· Speech and language evaluation by a speech pathologist
· Lead screening
· Medical evaluation including history and physical exam
· Specific screening for Autism
· Neuroimaging studies when the child is a candidate for surgical intervention such as surgery for epilepsy
· Occupational therapy and/or physical therapy when sensory motor deficiencies or motor planning is present
· Sensorial Integrated Treatment
· Quantitative testing for amino acids to determine phenylketonuria
Triple – S will cover for payment these services when any of the following criteria is met:
· Loss of language or social skills at any age
· Absence of babbling by 12 months of age
· Absence of gestures (pointing) by 12 months of age
· Absence of pronouncing ONE word by 16 months of age
· Absence of pronouncing TWO words in a phrase by 24 months of age
Triple-S will cover for payment behavioral treatment in cases of ASD when all of the following criteria are met:
· Criteria for ASD according to “Diagnostic and Statistical Manual of Mental Health Disorders” Fifth Edition, Text Revision (DSM-V-TR).
· Services are appropriate in type, frequency, extent, site and duration
· Services are provided by a professional staff in the behavior area
· When it is expected that the therapy produces a measurable improvement
Triple-S will cover for payment, genetic testing for the following situations:
· Genetic testing for mutations in the FMR1gene when the Fragile-X syndrome is suspected in presence of dysmorphologic characteristics or mental retardation.
· Genetic testing for mutations in the MECP2 gene when presence of Rett’s syndrome is suspected.
· Pre-pregnancy genetic testing to determine presence of a carrier when there is positive family history of the Fragile-X syndrome or Rett’s syndrome in a relative of first or second line of consanguinity.
· Prenatal tests to the fetus (amniocentesis or biopsy of the chorionic villus sampling (CVS) when any parent is a known carrier of the FMR1 or MECP2 genes.
As expressed in the Welfare, Integration and Development of Individuals with Autism Law (BIDA in Spanish), Law No. 220 – 2012, of September 4, 2012 *, cognitive rehabilitation is considered for payment under autism conditions.
Triple-S does not consider for payment:
· Allergy tests
· Antibodies tests for “Celiac Disease”
· Peroxidase erythrocyte glutathione studies
· Evoked potentials
· Hair analysis
· Heavy metals tests
· Immunological or neurochemical tests
· Intestinal permeability tests
· Magnetoencephalography
· Vitamin levels
· Lactate and pyruvate tests
· Tests of Chelation for mercury
· Urinary tests for peptides
Triple-S does not consider for payment the following therapies:
· Acupuncture
· Art Therapy
· Auditory interaction training
· Alternate communication
· Chelation Therapy
· Craniosacral Therapy
· Dietary and Nutritional Intervention
· Feedback
· Equestrian Therapy
· Facilitated Communication
· Hyperbaric Oxygen Therapy
· Immunoglobulin
· Music therapy
· Recreational Therapy
· Secretin Infusion
· Vision Therapy
